Thrombolysis or Surgery in Patients With Obstructive Mechanical Valve Thrombosis: The Multicenter HATTUSHA Study

J Am Coll Cardiol. 2022 Mar 15;79(10):977-989. doi: 10.1016/j.jacc.2021.12.027.


Background: Prosthetic valve thrombosis (PVT) is one of the life-threatening complications of prosthetic heart valve replacement. Due to the lack of randomized controlled trials, the optimal treatment of PVT remains controversial between thrombolytic therapy (TT) and surgery.

Objectives: This study aimed to prospectively evaluate the outcomes of TT and surgery as the first-line treatment strategy in patients with obstructive PVT.

Methods: A total of 158 obstructive PVT patients (women: 103 [65.2%]; median age 49 years [IQR: 39-60 years]) were enrolled in this multicenter observational prospective study. TT was performed using slow (6 hours) and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen activator (t-PA) (25 mg) mostly in repeated sessions. The primary endpoint of the study was 3-month mortality following TT or surgery.

Results: The initial management strategy was TT in 83 (52.5%) patients and surgery in 75 (47.5%) cases. The success rate of TT was 90.4% with a median t-PA dose of 59 mg (IQR: 37.5-100 mg). The incidences of outcomes in surgery and TT groups were as follows: minor complications (29 [38.7%] and 7 [8.4%], respectively), major complications (31 [41.3%] and 5 [6%], respectively), and the 3-month mortality rate (14 [18.7%] and 2 [2.4%], respectively).

Conclusions: Low-dose and slow/ultraslow infusion of t-PA were associated with low complications and mortality and high success rates and should be considered as a viable treatment in patients with obstructive PVT.

Keywords: echocardiography; prosthetic valve thrombosis; surgery; thrombolytic therapy; transesophageal echocardiography.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Adult
  • Female
  • Fibrinolytic Agents / adverse effects
  • Fibrinolytic Agents / therapeutic use
  • Heart Valve Diseases* / complications
  • Heart Valve Prosthesis* / adverse effects
  • Humans
  • Male
  • Middle Aged
  • Thrombolytic Therapy / adverse effects
  • Thrombolytic Therapy / methods
  • Thrombosis* / complications
  • Thrombosis* / etiology
  • Tissue Plasminogen Activator / adverse effects
  • Tissue Plasminogen Activator / therapeutic use
  • Treatment Outcome


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator